In Practice: Reflections from NPs and PAs

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

 

“You little clown,” A fleck of saliva flew from his mouth with each word. “Are you making a joke?”

The back of my neck grew hot as I sweltered under the man’s glare. He had arrived to the airport hours before his scheduled flight dragging his wife and three kids, depleted from a week at Disney World, through a mile-long trek of check-in lines and security checkpoints before finally arriving at the international departures terminal. But a 30-minute delay had stretched and multiplied and, as the sun dipped under the horizon, word arrived from the airport mechanics that the flight was cancelled. The airline offered consolation: a $15 meal voucher and an expanse of stained airport carpet on which to sleep.

“I can’t feed myself with this much less three kids…” the rant dissolved into a stream of profanity as his sunburned cheeks somehow glowed an even brighter shade of red. Behind him, 400 more passengers waited with similar sentiments.

Of course, the 17-year-old version of me who stood in front of that verbal firing squad had no control over flight cancellations or the value of food coupons. Wading through my first summer job at the airport, the only decision I really made was which soda to pick from the vending machine during my break. But looking back, I realize I was really only paid to do one thing in the high-octane service industry of air travel: to buffer that angry energy like a human shock absorber.

Whether we like to admit it or not, healthcare is a service industry, too. And it always has been. After all, the revered small-town doctor who once made house calls with his little black bag was just providing a service. If something has changed since those days, it’s that our competition now includes self-diagnosis by Dr. Google, our ER wait times are advertised on billboards, and our app-powered society has turned patience from a virtue to a cardinal sin.

We see more patients with less time. Our fuses are half as long and burn twice as fast.

That means you don’t need to be a bad clinician to face your fair share of anger and resentment. An upset patient is not unlike those disgruntled passengers waiting in the airport: exhausted, frustrated, and in desperate need of good news. And while you hopefully don’t have a 747’s worth of patients outside of your office, the lesson might be the same.

We can’t rely on an extra pain medication refill or the not-so-indicated antibiotics to buy our patient’s happiness. That airport food voucher did little to appease my passengers. What they really wanted was for someone to stand at attention and listen.

I hear jokes about how the ER has turned into the Value Menu at McDonald’s or how survey-based reimbursement means primary care clinicians are now working for tips. I get the punch lines: we have transformed from scientist-artists to the customer complaint department, from steward to servant.

But maybe that’s not really the change we’re all feeling. Maybe the role is the same, but it’s just missing a key component. We’ve shifted from small businesses to hospital mega-systems. The communities we support have become larger, more complex, and more transient. Our priorities are determined in corporate boardrooms instead of at the bedside.

Maybe, all along, the only thing that separated us from other industries was the relationships we had with those we serve. And maybe, in our current system, those relationships no longer seem feasible.

I don’t have a quick fix for a healthcare system that seems to swallow the individual to feed the conglomerate. But I can focus on something smaller. If I face someone exhausted from his journey, frustrated by setbacks and looking for answers, I have two choices: I can ignore, deflect, or lash out at his emotion. Or I can be a small moment of relief in his otherwise savage world.

I chose medicine because I wanted to be like that small town doctor with his little black bag, the one everyone knew and trusted, like my grandfather I grew up hearing stories about. And maybe I don’t have those bonds forged over decades of dedicated care, but I’ve learned that isn’t the only definition of relationship. A relationship can start with a handshake at the exam room door, a word of encouragement when treatment fails, or a hug when all seems lost.

Those small gestures might sound trivial as millions of lives hang in the balance. But each one of us makes those tiny decisions all day long. And when they add up, it might be the only thing that separates a service industry from an industry that serves.